Case Modification Request - A2Z Diagnostics

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Case Modification Request

Office Name *

Patient Name *

First

Middle

Last

Requested Change

Patient Name
ICD Code
Passport Number
Date of Collection
Time of Collection
Other

Patient Name Error *

First

Middle

Last

ICD Codes

Z20.822 - Contact with and (suspected) exposure to COVID-19
Z86.16 - Personal history of COVID-19
U07.1 - COVID-19
J12.82 - Pneumonia due to coronavirus disease 2019
R05 - Cough
R06.02 - Shortness of breath
R50.9 - Fever Unspecified
J11.1 - Flu Like Symptoms
J02.9 - Pharyngitis, unspecified
R09.81 - Nasal Congestion
R68.83 - Chills (without fever)

Comments:

Submitters Name *

First

Last

I am authorizing changes be made as stated. *

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